Professional claim · CMS-1500 · Provider portal
CLM-2026-010005
Lakeside Medical Group, Family Medicine. Service 2025-12-19 at office (POS 11). Received 2026-01-21.
ApprovedOut of network
Billed
$309.00
3 lines
Allowed
$139.05
contract rate applied
Plan pays
$127.80
approved
Member owes
$11.25
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Ruth Fisher
- Member ID
- UHC-47109-24
- Date of birth
- 1968-10-20
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-408668
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2348
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,577.79 of $2,500.0063%
- Out-of-pocket maximum
- $2,140.41 of $7,500.0029%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 4961481189
- Network
- Out of network
- Rendering NPI
- 2012692242
- Location
- Mesa, AZ · TIN 54-1409504
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 36415 | Venipuncture | — | 1 | 1 | $25.00 | $11.25 | $11.25 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $241.00 | $108.45 | $0.00 | $108.45 | Paid |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $43.00 | $19.35 | $0.00 | $19.35 | Paid |
| Totals | $309.00 | $139.05 | $11.25 | $127.80 | ||||||
Diagnoses (ICD-10-CM)
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
Claim header
- Patient account
- PA-686041
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006286 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-19: OPTIONS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2025-12-19 18:20
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$309.00
Plan discount
$169.95
out-of-network allowance
Plan paid
$127.80
You may owe
$11.25
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003600 | 2026-07-18 | Pinecrest Behavioral Health | $656.00 | Approved |
| CLM-2026-014517 | 2026-04-12 | Northgate Medical Group | $700.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.